1801006139 - long case

 

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  A 55 year old male who is a resident of Miryalaguda and vegetable vendor by occupation presented to the General Medicine O.P.D with chief complaints of 

• Shortness of Breath 20 days ago
• Swelling of both lower limbs 10 days ago

History of Presenting Illness:

     Patient was apparently asymptomatic 20 days back then he developed shortness of breath which was insidious in onset which was initially on exertion, now progressed to symptoms even while rest (NYHA GRADE-4).

Patient also complains of breathlessness on lying down in supine position , relived in sitting position.(orthopnea)

Patient also complains of pedal edema 10 days ago which was insidious in onset and gradually progressed till knees.

No history of chest pain, palpitations, sweating

No history of Fever, cough

No history of decreased urine output.

No history of wheeze, hemoptysis, PND

No history of chest tightness, 

History of Past Illness:

Not a known case of Diabetes Mellitus, Hypertension, Asthma, Tuberculosis, Coronary Artery Disease, Epilepsy, Stroke.

Personal History:

 

Patient takes mixed diet, appetite is good, Bowel and Bladder movements are Regular, Sleep is Disturbed.

Patient consumes 90ml of alcohol ocasionally for the past 10 years,

chews gutka for the past 15 years.

 

Treatment History:

Patient used NSAIDS for back pain once in every 2-3 days for the past 3 years.

Family History:

No significant family history.

General Examination:

After taking consent, Patient is examined in a well lit room after adequately exposed.

Patient is conscious, coherent and cooperative and well oriented to time place and person.

Patient is moderately built and moderately nourished.

PALLOR - Absent

ICTERUS - Absent

CYANOSIS - Absent

CLUBBING - Present, Bilateral, Pandigital

 

 

 

 

 

 

 

 

 

 GENERALIZED LYMPHADENOPATHY - Absent

       

PEDAL EDEMA - Grade 2 (Till knees),Bilateral, Painless, Pitting type.

 

 

VITALS:

Temperature - Afebrile

Blood Pressure - 130/70 mm Hg

Pulse Rate - 66bpm, regular.

Respiratory Rate - 22cpm

GRBS - 92mg/dl

Systemic Examination:

 

 CARDIOVASCULAR SYSTEM EXAMINATION:

 

    JVP is raised

    Inspection:

    Chest wall shape is Normal

    Precordial bulge is absent 

   Kyphoscoliosis is not seen

    No dilated veins ,scars, sinuses

    Apical impulse is not seen

    No pulsations are seen.

 

    Palpation:

    Kyphoscoliosis absent

    Apical Impulse - Position: Felt at 6th ICS 2cm lateral to mid clavicular line

 Character: Diffuse and sustained

 

 No pulsations felt

    No Thrills felt

    No dilated veins felt

 

    

    Auscultation:

    Mitral Area - S1 S2 heard , No added murmurs.

    Tricuspid Area - S1 S2 heard , No Added murmurs

    Pulmonary area - S1 S2 heard , No added murmurs

    Aortic area - S1 S2 heard , No added murmurs

 RESPIRATORY SYSTEM EXAMINATION:

    Inspection - 

 

    Chest is symmetrical

    Trachea is midline

    No retractions

    No kyphoscoliosis

    No Winging of scapula

    No Scars, sinuses, Dilated Veins

    All areas move equally and symmetrically with respiration

 

    Palpation - 

 

    Trachea is Midline

    No tenderness, no local rise in temperature

    Tactile Vocal Fremitus 

        

                                             Right           Left
    Supra clavicular:        Present       Present   
    Infra clavicular:         Present       Present 
    Mammary:                 Present        Present

    Infra mammary:      Diminished    Present
    Axillary:                      Present         Present
    Infra axillary:     Diminished  Diminished
    Supra scapular:        Present          Present
    Infra scapular:         Diminished     Present
    Inter scapular:          Present          Present

 

 

    Percussion - 

 

                                             Right               Left
    Supra clavicular:        resonant  resonant   
    Infra clavicular:          resonant  resonant 
    Mammary:                  resonant   resonant

    Infra mammary:      DULLNESS  resonant
    Axillary:                      resonant    resonant
    Infra axillary:     DULLNESS DULLNESS
    Supra scapular:         resonant    resonant
    Infra scapular:         DULLNESS resonant
    Inter scapular:           resonant    resonant  

    No tenderness

    Auscultation - 

                                           Right.            Left

    Supra clavicular:.     NVBS            NVBS
    Infra clavicular:        NVBS            NVBS
    Mammary:                 NVBS           NVBS    

    Infra mammary:   Diminished     NVBS
    Axillary:                     NVBS            NVBS
    Infra axillary:   Diminished  Diminished
    Supra scapular:       NVBS             NVBS
    Infra scapular:      Diminished     NVBS    
    Inter scapular:         NVBS             NVBS

 

    Vocal Resonance 

                                       Right                Left

    Supra clavicular:  Resonant      Resonant
    Infra clavicular:    Resonant      Resonant
    Mammary:             Resonant      Resonant

    Infra mammary:   Diminished  Resonant
    Axillary:                  Resonant      Resonant
    Infra axillary:  Diminished  Diminished
    Supra scapular:    Resonant      Resonant
    Infra scapular:      Diminished  Resonant
    Inter scapular:      Resonant      Resonant

 

    No added Sounds

 

CENTRAL NERVOUS SYSTEM EXAMINATION

   Higher Mental Functions intact

    

    Cranial nerve Examination - Normal

    Sensory Examination  - Normal

    Motor Examination - Normal

    Neck Rigidity - Absent

    Kernigs sign - Negative

    Brudzinskis sign - Negative 

 

 ABDOMINAL EXAMINATION:

    Soft

    No tenderness

    No Hepatomegaly

    Spleen is not palpable

    Bowel sounds are heard

 

PROVISIONAL DIAGNOSIS :

    HEART FAILURE WITH BILATERAL PLEURAL EFFUSION

 

 

INVESTIGATIONS 

 

 

 

 

 

 

 

 

 

 

 CHEST X RAY:

 

 

 

 

 

Findings: 

       Obliteration of right sided costo phrenic angle

        Enlarged Cardiac silhoutte

        Cardio Thoracic Ratio is more than 0.5 

 

 

ULTRASONOGRAM FINDINGS:

• BILATERAL GRADE 2 RENAL PARENCHYMAL  CHANGES
• BILATERAL MILD PLEURAL EFFUSION
• DILATED INFERIOR VENA CAVA AND HEPATIC VEINS-CONGESTIVE CHANGES
  

COLOR DOPPLER 2D ECHO:

•  LEFT VENTRICLE - GLOBAL HYPOKINETIC, MODERATE TO SEVERE DYSFUNCTION.
• RIGHT ATRIUM, LEFT ATRIUM, RIGHT VENTRICLE ARE DILATED 
• DIASTOLIC DYSFUNCTION
•  INFERIOR VENA CAVA DILATED , NON COLLAPSING
• EJECTION FRACTION - 38%
  

 ELECTROCARDIOGRAM:

 

 

 

FINAL DIAGNOSIS : 

HEART FAILURE WITH REDUCED EJECTION FRACTION WITH BILATERAL PLEURAL EFFUSION

TREATMENT:

1. INJECTION LASIX 40mg IV BD
2. FLUID RESTRICTION <1lit/day and salt restriction
3. TAB. ECOSPRIN PO
4. TAB MET XL 12.5mg PO
5. INJECTION THIAMINE 200mg Direct IV BD
6. PANTOP 40 mg PO BD